2850 Artesia Blvd. Suite #204, Redondo Beach, CA 90278 3440 Lomita Blvd. Suite #137, Redondo Beach, CA 90505

(310) 793-1158 - Ofc (310) 793-1161- Fax

www.RBPodiatry.com

Podiatry Offices of Phillip Darragh, DPM

Robert Anavian, DPMV. Greg Krall, DPM

Jonathan J. Pirak, DPM

Foot Pain | General Podiatry | Sports Medicine Diabetic Foot Management | Foot and Ankle Surgery

To Our New Patient:

Welcome to Redondo Beach Podiatry Group! We are thrilled that you have chosen our team for your foot and ankle needs. We will do our best to provide you with the most up-to-date and comprehensive podiatric care available. We have a total commitment to keeping your feet healthy – and keeping you happy.

To maximize your time with us, we ask that you bring the following to your first visit: photo identification, medical insurance card(s), written referral (if required by your insurance company), and prior medical records and x-rays (if applicable).

In addition, please complete and sign the New Patient Forms included with this letter. These include our Patient Registration, Comprehensive Health Review (include all current medications and dosages), and Consent to Treat.

Whether you have a serious foot health condition or you’re just looking for added comfort, Redondo Beach Podiatry Group is here to provide the best podiatric care possible. We look forward to your appointment with us!

Sincerely,Redondo Beach Podiatry Group

PS – Please visit us online at www.RBPodiatry.com for additional patient information and our Notice of Privacy Policies.

PATIENT REGISTRATION

PATIENT INFORMATION Patient’s Last Name  First  Middle  Marital Status (Circle One)  Mr.     Mrs.     Dr.

 Miss     Ms. Single  /  Mar  /  Div  /  Sep  /  Wid 

Nickname (Name I preferred to be called)  Birth Date (mm/dd/yyyy)  Sex  Spouse’s Name 

 M   F

Street Address   Social Security #  Home Phone # 

(          ) 

City  State  Zip Code  E‐Mail  Mobile Phone # 

(          ) 

Employer  Employer Address  Employer/Work Phone # 

(          ) 

How Did You Hear About Us  Primary Care Physician (PCP) - Name /Phone#  Date PCP Last Seen 

PERSON RESPONSIBLE FOR BILL    (IF DIFFERENT THAN ABOVE)Name of Person Responsible for Bill  Birth Date (mm/dd/yyyy)  Sex  Relationship to Patient 

 M   F   Self     Spouse    Child    Other

Street Address   Social Security #  Home Phone # 

(         ) 

City  State  Zip Code  E‐Mail Mobile Phone # 

(          ) 

Employer  Employer Address  Employer/Work Phone # 

(          ) 

INSURANCE INFORMATION    (PLEASE GIVE YOUR INSURANCE CARD AND PHOTO ID TO RECEPTIONIST) Primary Insurance  Subscriber Name  Birth Date (mm/dd/yyyy)  Social Security # 

Insurance ID #  Group #  Policy #  Effective Date  Expiration Date  Co‐Payment 

$ 

Secondary Insurance  Subscriber Name  Birth Date (mm/dd/yyyy)  Social Security # 

Insurance ID #  Group #  Policy #  Effective Date  Expiration Date  Co‐Payment 

$ 

IN CASE OF EMERGENCY Name of Nearest Friend or Relative  Relationship to Patient  Home Phone #  Work or Mobile Phone # 

  (          )  (          ) 

PHARMACY INFORMATION Pharmacy Name & Address:

 CVS   Rite-Aid   Walgreens   Target Phone Number

The above  information  is  true  to  the best of my knowledge.  I certify  that  I have  insurance with  the  insurance company(ies) disclosed and assign directly  to Redondo Beach Podiatry Group all insurance benefits, if any, otherwise payable to me for service(s) rendered.  I understand that I am financially responsible for all charges whether or not paid by my  insurance.    I authorize the use of my signature below on all  insurance submissions.   Redondo Beach Podiatry Group may use my health care information  and may  disclose  such  information  to  the  disclosed  insurance  company(ies)  and  their  agents  for  the  purpose  of  obtaining  payment  for services  and determining insurance benefits or the benefits payable for related services. 

X 

PATIENT/GUARDIAN SIGNATURE  DATE 

Other

COMPREHENSIVE HEALTH REVIEW

Patient Name: _____________________________________  Date of Birth: ________________   Today’s Date: ________________ HISTORY OF PRESENT ILLNESS / WHAT BRINGS YOU IN? 

What is your specific foot/ankle problem?  Which foot/ankle is involved?    Right      Left    Both 

First visit to a doctor for this problem?    Yes       No 

Have you had a similar problem in the past?    Yes       No 

When did the problem begin?  How was the problem onset?    Sudden      Gradual  

The problem is:    Improving     Worsening     Unchanged  The problem is worst:   AM     PM     At Rest     With Activity 

What aggravates the problem?  What improves the problem? 

Is the problem painful?    Yes     No  If so, rate your current pain:  (none) 0   1    2    3    4    5    6    7    8    9   10 (worst) 

Describe the pain:   Sharp   Dull   Aching   Throbbing   Cramping   Itching   Popping 

   Burning   Tingling   Clicking   Shooting   Stabbing   Other: 

Describe previous treatments: 

Is this from an injury?    Yes     No  If so, is it work‐related?     Yes     No 

PAST MEDICAL HISTORY   PAST SURGERIES   Diabetes    Type  1  2   Duration ____ years   Last Blood Sugar _____  HbA1c  ____    Foot/Ankle Surgery: _____________________   Acid Reflux   Liver Disease (  Hepatitis)   Joint Replacement: ______________________ 

  Anemia    Leg Cramps/Leg Pain at Rest   Open Heart/Bypass Surgery 

  Anesthesia Complications    Lung Condition:  ________________      Hysterectomy     Tubal ligation     C‐Section 

  Arthritis (  Osteo /   Rheum)    Mitral Valve Prolapse/Murmur    Stent Placement:  Heart   Leg 

  Asthma    Multiple Sclerosis    Cosmetic Surgery: _______________________ 

  Back Problems/Sciatica    Nervous Disorder/Depression   Appendix     Gallbladder     Tonsils/Add 

  Blood Clot/DVT    Neuropathy   Leg Bypass     Open Fracture Repair 

  Cancer: _______________________    Osteomyelitis/Bone Infection   Carotid Surgery      Vein Surgery 

  Cellulitis/Skin Infection (  MRSA?)    Parkinson’s Disease    Hernia repair      Thyroid      Back surgery 

  Circulation Problem    Previous Addiction to:  ___________    Other: ________________________________ 

  Dementia/Alzheimer’s    Pulmonary Embolism 

  Excessive/Easy Bleeding    Rashes/Skin Condition FAMILY HISTORY (circle relative) 

  Fibromyalgia    Raynauds Disease/Phenomena   Mother   Father   Sister   Brother   GrandParent 

  Foot/Leg Ulcer    Seizure Disorder/Epilepsy    Cancer  M  F  S  B  GP 

  Gout    Sickle Cell Disease/Trait   Diabetes  M  F  S  B  GP 

  Healing Problems/Keloids    Sleep Apnea   Gout  M  F  S  B  GP 

  Heart Disease/Heart Attack    Stomach Ulcers   Heart Disease  M  F  S  B  GP 

  High Blood Pressure (   Low BP?)    Stroke     Rt    Lt  (year ______)    High Blood Pressure  M  F  S  B  GP 

  High Cholesterol    Thyroid Condition (  Hi     Lo)   Severe Arthritis  M  F  S  B  GP 

  Hormone Therapy    Varicose Veins   Anesthesia Complications  M  F  S  B  GP 

  Immune Disorder/HIV    Women – Are You Pregnant or     Foot Problems  M  F  S  B  GP 

  Kidney Disease (  Dialysis) Breast Feeding? 

  Other:  _______________  M  F  S  B  GP 

  Other problems not listed: 

PAGE 1 OF 2 

COMPREHENSIVE HEALTH REVIEW 

Patient Name: ____________________________________________ MEDICATIONS (include RX meds, OTC meds, and vitamins)  ALLERGIES Medication  Dosage Medication  Dosage    None    Latex 

  Adhesives/Tape    Local Anesthetics 

  Aspirin    Penicillin 

  Codeine    Seafood/Shellfish 

  Cortisone    Sulfa Drugs 

  Iodine      

SOCIAL HISTORY 

Occupation:  I Stand ______ % of My Day 

  I Drink Alcoholic Beverages   How much/often?  I Exercise Each Week:    0 days     1‐2 days     3+ days 

  I Use or Have Used Tobacco Products  Type:  List Sports/Activities: 

Packs/Day    Years  When Stopped? 

  I Use or Have Used Drugs that are Illegal 

I Live With:    No One     Spouse     Children     Parents     Other    My foot/ankle problem limits my activities 

REVIEW OF SYSTEMS 

CONSTITUTIONAL Recent Weight ChangesFever/ChillsNausea or VomitingFatigue

EYES Eye Disease/InjuryWear Glasses/ContactsBlurred or Double visionGlaucoma

EARS/NOSE/MOUTH/THROAT Hearing Loss Nose Bleeds Sore Throat/Voice ChangeSinus ProblemsDifficulty Swallowing

CARDIOVASCULAR Chest PainPalpitationsArrhythmia/Irregular Heart BeatLeg Pain when WalkingSwelling of Hands/Feet

MUSCULOSKELETAL Muscle Pain or CrampsJoint PainStiffness/Swelling JointsLow Back PainTrouble Walking

GASTROINTESTINAL Indigestion/HeartburnDiarrheaBlood in StoolsStomach Pains

RESPIRATORY Shortness of BreathChronic/Frequent CoughWheezing

GENITOURINARY Frequent UrinationPainful UrinationKidney StonesBlood in Urine

INTEGUMENTARY Rash or ItchingDry SkinChange in Hair/Nails

HEMATOLOGICAL Bruise EasilySlow to Heal

ENDOCRINE Hormonal ProblemExcessive ThirstExcessive UrinationToo Hot/Too Cold

NEUROLOGICAL MigrainesFrequent HeadachesNumbness/TinglingDizzy SpellsParalysis/Tremors

PSYCHIATRIC AnxietyDepressionNervousness InsomniaConfusion/Memory Loss

STATS For Office Staff BMI _________

Age ______   Height ________   Weight ________   Shoe Size _______  BP _________   P _________    O2 Sat _________   Temp ________ 

I understand that completing this paperwork  is a chore.   The  information  I have provided  is true to the best of my knowledge.    I recognize that the information I have provided will help me receive better care.  I thank you for taking such an interest in my health.

XPATIENT/GUARDIAN SIGNATURE  DATE  PAGE 2 OF 2 

FINANCIAL POLICY 

1. All co‐payments are due at the time of visit.  This arrangement is part of your contract with your insurance company.  Failure on our part to collect co‐payments and deductibles from patients can be considered a violation of the contract you have with your insurance company.  Our office accepts cash, checks (post‐dated checks are not accepted), credit and debit cards.

2. Co‐insurance and unmet deductibles are due prior to scheduled surgeries and procedures.  Once benefits are verified and your financial responsibility calculated, you will be notified of the payment amount and due date.

3. You are ultimately responsible for payment of charges for services you receive from our office.

4. In accordance with your insurance member handbook, it is your responsibility to provide accurate insurance information and to present your insurance ID card at the time of your visit.  If you do not have insurance or do not present a valid insurance card, you will be responsible for payment at the time of service.  We will provide you with a copy of our billing form so that you can obtain reimbursement from your insurance company.

5. It is your responsibility to ensure that our physicians are in your insurance network.

6. If your plan requires a referral, it is your responsibility to obtain this prior to being seen by our provider.

7. Payment is due for rendered services 10 days from receipt of your billing statement.  Outstanding balances must be paid in full prior to any additional visit unless arrangements have been made with our billing department.

8. There is a service fee of $35 for each time a check is returned.   The bank may return your check up to three times before considering it nonnegotiable.  Your insurance company does not cover this fee.

9. A scheduled appointment means that time has been reserved for you.  Cancellations for appointments must be received at least 24 hours prior to the scheduled appointment.  Cancellations for scheduled surgery and in‐office procedures must be received at least 5 days prior to the scheduled surgery date and time.

10. Patients who fail to keep or fail to cancel a scheduled appointment may be charged a $25.00 No Show Fee.  There is a $100.00 cancellation fee for scheduled surgeries or in‐office procedures that are cancelled less than 5 business days from the date and time of surgery unless cancellation is due to insurance denial or medical necessity.

11. Medical records requests must be received in writing at least 72 hours prior to the date needed.  Fees must be received prior to record delivery. No more than 5 pages may be faxed.

12. Administrative Services:  There is a $25.00 charge for each required Administrative Service, payable prior to service completion.  This Administrative Service Fee covers specific administrative services such as forms completion for family medical leave and disability, letters for insurance authorizations for brand or non‐formulary drugs, letters for employers, school, health clubs, and any other administrative items not covered by insurance.

13. In the event your insurance company should happen to send payment to you (the patient), youagree to forward said payment to our office to be applied to your account.

14. SELF‐PAY:  Payment in full is due at the time of service if you do not have health insurancecoverage.

CONSENT TO TREATMENT

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Redondo Beach Podiatry Group Notice of Privacy

Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice.

AUTHORIZATION REGARDING PRIVACY POLICY

Due to the recent implementation of the Patient Privacy Act (HIPPA), I hereby authorize Redondo

Beach Podiatry Group to leave messages at my home with family members and/or answering

machines regarding the following: (1) Confirm or Change Appointment, (2) Results of testing

ordered by the physician, and/or (3) Any pertinent information that may be relative to my care.

ACKNOWLEDGMENT OF RECEIPT OF FINANCIAL POLICY

I acknowledge that I was provided a copy of the Redondo Beach Podiatry Group Financial Policy and

that I have read (or had the opportunity to read if I so chose), understand and will comply by the

policies stated.

CONSENT TO VIEW EXTERNAL PRESCRIPTION HISTORY

I authorize Redondo Beach Podiatry Group to view my external prescription history via electronic

prescribing services. I understand that prescription history from multiple other unaffiliated medical

providers, insurance companies, pharmacies and pharmacy benefit managers may be viewable by

my provider and staff at Redondo Beach Podiatry Group and it may include prescriptions back in

time for several years.

PATIENT CONSENT

I hereby voluntarily consent to outpatient care by a Redondo Beach Podiatry Group Podiatrist,

encompassing routine care, diagnostic procedures, examination and medical treatment including,

but not limited to, minor surgical procedures, routine laboratory work, x-rays,

ultrasound, photographs and administration of medications and injections prescribed by the

Redondo Beach Podiatry Group Podiatrist. I agree to ask questions to clarify treatment should I not

understand the treatment plan.

INSURANCE ASSIGNMENT AND RELEASE

I certify that I have insurance with the insurance company(ies) disclosed and assign directly to

Redondo Beach Podiatry Group and its Podiatrists, all insurance benefits, if any, otherwise payable

to me for service(s) rendered. I understand that I am financially responsible for all charges

whether or not paid by my insurance. I agree that should my account become delinquent and

is referred to an attorney or collection agency for collection, I will be charged an additional 33 1/3%

of any unpaid balance at the time of referral for all costs of collection and attorney's fees. I

authorize the use of my signature below on all insurance submissions.

Redondo Beach Podiatry Group may use my health care information and may disclose such

information to the disclosed insurance company(ies) and their agents for the purpose of

obtaining payment for services and determining insurance benefits or the benefits payable for

related services.

DISCLOSURE OF SERVICES

I understand that Redondo Beach Podiatry Group is owned and operated by Dr. Darragh. During

my course of treatment, products may be recommended. I understand that I am under no

obligation to purchase these products and that i may find alternate sources to purchase these products.

Patient Initials:

Patient Initials: ---

Patient Initials:

Patient Initials:

Patient Initials: ---

Patient Initials:

Patient Initials: ---

I have read and fully understand this Consent to Treatment. This authorization is valid as of the date I have signed below

and will remain in effect as long as I am a Redondo Beach Podiatry patient. I have read this complete page and agree to all of

its contents.

Name of Individual/Legal Representative (Print) Signature of Individual/Legal Representative Date

---

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Foot Pain | General Podiatry | Sports Medicine Diabetic Foot Management | Foot and Ankle Surgery

HIPAA Notice of Privacy Practices

Written Acknowledgment Form

Our Notice of Privacy Practices (NPP) provides information about how we may use and disclose

medical information about you.

I, _____________________ (print patient name), with the date of birth ________________ (print

patient date of birth) have been provided access to a copy of the Redondo Beach Podiatry Group's NPP for review.

This acknowledgment form will be in effect until otherwise revoked by Redondo Beach Podiatry in writing.

I hereby consent to the release of any/all information regarding my medical history, current

medical condition, current medical treatment and any/all patient account information to the

individual(s) listed below: (If you would not like any information to be released please leave

blank).

______________________________ __________________ _________________

Name Relationship Phone Number

______________________________ __________________ _________________

Name Relationship Phone Number

______________________________ __________________ _________________

Name Relationship Phone Number

_______________________________________ ____________________

Patient Signature Date

_______________________________________ ____________________

Witness Signature Date

2850 Artesia Blvd. Suite #204, Redondo Beach, CA 90278 3440 Lomita Blvd. Suite #137, Redondo Beach, CA 90505

(310)10) 793-1158 - Ofc (310) 793-1161- Fax

www.RBPodiatry.com